Sports Physicals & Sudden Cardiac Death: What Are We Screening For?

We’ve all seen the headline: a student athlete collapses on the field. It’s terrifying every time, and even more unsettling because these are often kids who seemed completely healthy moments before. Stories like these stay with us. They should also remind us why preparticipation screening matters. But on a busy day in clinic when there’s a sports form in front of us, it’s worth the reminder: what are we actually screening for?

The real goal of the sports physical

Approximately 51% of children and adolescents (ages 6-17) participate in organized sports in the United States. That means millions of athletes are stepping onto fields, courts, tracks and into pools each year. Though precise incidence is uncertain, sudden cardiac death (SCD) remains uncommon, occurring in roughly 0.5-2 athletes per 100,000 annually. Yet when it happens, the impact is devastating for families, teammates, schools, and communities.

It’s easy to think of the preparticipation evaluation (PPE) as a clearance exam, but in reality, the PPE serves two important purposes. First, it aims to identify potentially life-threatening cardiovascular, neurologic, or systemic conditions that could place an athlete at risk during sport participation. Second, it helps uncover medical issues that may interfere with athletic performance or increase injury risk, such as exercise-induced bronchospasm, poorly controlled asthma, prior concussions, musculoskeletal injuries, or other chronic medical issues. The cardiovascular portion tends to receive the most attention — and for good reason. While rare, sudden cardiac arrest is often the event that everyone hopes to prevent.

What causes sudden cardiac death in young athletes?

Some people assume that when a young athlete collapses during competition, they must have had a previously known heart problem. Often, that’s not the case.

Hypertrophic cardiomyopathy (HCM) is one of the most common causes of sudden cardiac death among pediatric and young adult athletes in the United States, accounting for approximately ⅓ of cases. Other important causes include: dilated cardiomyopathy, arrhythmogenic cardiomyopathy, long QT syndrome, short QT syndrome, Wolff-Parkinson-White (WPW) syndrome, Brugada syndrome, catecholaminergic polymorphic ventricular tachycardia (CPVT), anomalous coronary arteries, myocarditis, significant valvular heart disease, and commotio cordis following blunt chest trauma.

These conditions all share one frustrating characteristic: many affected athletes appear completely healthy until symptoms occur or a catastrophic event happens.

The four questions every clinician should know

The American Academy of Pediatrics actually recommends screening all children, regardless of sports participation, at least every 3 years and at key transitions into middle school and high school. Screening centers around four focused questions that can reveal clues that might otherwise go unnoticed during a routine visit:

1. Have you ever fainted, passed out, or had an unexplained seizure suddenly and without warning, especially during exercise or after a sudden loud noise?
2. Have you ever experienced exercise-related chest pain or shortness of breath?
3. Has anyone in your family died unexpectedly before age 50 from a heart problem, or experienced an unexplained drowning, motor vehicle crash, or sudden infant death?
4. Do you have relatives with conditions such as hypertrophic cardiomyopathy, Marfan syndrome, Long QT syndrome, Brugada syndrome, CPVT, or implanted pacemakers or defibrillators before age 50?

The athlete-specific approach

For athletes, the American Heart Association recommends a broader 14-point screening tool that includes both history and physical examination components.

The personal history focuses on exertional symptoms, including chest pain, syncope, unexplained fatigue, palpitations, prior sports restrictions, heart murmurs, hypertension, and previous cardiac evaluations. Family history explores premature cardiac death, disability from heart disease, and inherited cardiac conditions.

The physical exam looks for findings, such as:

• Pathologic heart murmurs
• Femoral pulse abnormalities suggesting coarctation
• Physical findings consistent with Marfan syndrome
• Elevated blood pressure

A single concerning history or PE finding doesn’t automatically mean an athlete is unsafe to participate, but it does signal that further cardiovascular evaluation may be warranted.

Why not just get an ECG?

We know that history and physical exam alone have a low sensitivity (~2-6%) of detecting cardiac conditions. So, why don’t we simply perform ECGs on everyone? The short answer is that screening everyone is more complicated than it sounds. While the AHA states that adding a resting 12-lead ECG is “reasonable”, universal screening does introduce some challenges such as false positives, downstream testing, cost, and access to expert interpretation. In fact, conditions such as anomalous coronary arteries, certain aortic disorders, and some adrenergically mediated arrhythmias (such as CPVT) may remain undetected despite normal ECG findings.

Screening is only half the job

For many patients, the PPE may be the only healthcare encounter they have all year. This means that we should capitalize on the opportunity to ask those screening questions, obtain a thorough history, and identify conditions that may be a barrier to safe sports participation.

One of the hardest truths about sports screening is that no strategy entirely eliminates the risk of sudden cardiac arrest. That’s why preparedness matters. Every school and athletic program should have a well-developed emergency plan that includes CPR-trained personnel, readily accessible automated external defibrillators (AEDs), and a coordinated emergency transport system. When sudden cardiac arrest occurs, rapid recognition and defibrillation may be the single most impactful intervention available.